Effectiveness and safety of non-vitamin K oral anticoagulants versus warfarin in patients with atrial fibrillation and previous stroke: A systematic review and meta-analysis.

Current evidence regarding the clinical outcomes of non-vitamin K oral anticoagulants (NOACs) versus warfarin in patients with atrial fibrillation (AF) and previous stroke are inconclusive, especially in patients with previous intracranial haemorrhage (ICrH). We aim to undertake a systematic review and meta-analysis assessing the effectiveness and safety of NOACs versus warfarin in AF patients with a history of stroke. We searched studies published up to 10th December 2022 on PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials. Studies on adults with AF and previous ischemic stroke (IS) or IrCH receiving either NOACs or warfarin and capturing outcome events (thromboembolic events, ICrH, and all-cause mortality) were eligible for inclusion. Six randomized controlled trials (including 19489 patients with previous IS) and fifteen observational studies (including 132575 patients with previous IS and 13068 patients with previous ICrH ) were included. RCT data showed that compared with warfarin, NOACs were associated with a significant reduction in thromboembolic events (OR 0.85, 95% CI 0.75-0.96), ICrH(OR 0.57, 95% CI 0.36-0.90) and all-cause mortality (OR 0.88, 95% CI 0.80 to 0.98). In analysing observational studies, similar results were retrieved. Moreover, patients with previous ICrH had a lower OR on thromboembolic events than those with IS (OR 0.66, 95% CI 0.46-0.95 versus OR 0.80, 95% CI 0.70-0.93) in the comparison between NOACs and warfarin. Observational data showed that in AF patients with previous stroke, NOACs showed better clinical performance compared to warfarin and the benefits of NOACs were more pronounced in patients with previous IrCH versus those with IS. RCT data also showed NOACs are superior to warfarin. However, current RCTs only included AF patients who survived an IS and further large RCTs focus on patients with previous ICrH are warranted.

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The Author(s). Published by S. Karger AG, Basel.